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Paul Rushton and Niall Eames
otherwise. A radiograph is not sensitive in this
pathology. The whole spine should be imaged
with CT scan and surgeons should have a low
threshold for MRI if negative: a negative CT does
not exclude a fracture. Fractures in the setting of
ankylosis are typically unstable given the long
lever arms involved and usually require operative
treatment with long segment instrumentation at
least 3 levels above and below the fracture. These
spines are osteoporotic, but these injuries have a
high neurological complication rate both at presentation, whils t awaiting treatment and after
surgery (Schwendner et al. 2021). Patients with
ankylosing spondylitis typically have significant
kyphotic deformity thus nursing flat in the presence of a fracture may effectively perform an
extension osteotomy for the patient and result
in a neurological deficit. The patient needs to be
nursed in the natural position of their spine
usually propped up with pillows to mimic the
kyphosed ‘normal’ position of their spine.
Akkoç N, Yarkan H, Kenar G, Khan MA.
Ankylosing spondylitis: HLA-B*27-positive
versus HLA-B*27-negative disease. Curr
Rheumatol Rep. 2017;19:26.
Schwendner M, Seule M, Meyer B, Krieg
SM. Management of spine fractures in ankylos-
ing spondylitis and diffuse idiopathic skeletal
hyperostosis: a challenge. Neurosurgical focus,
2021;51:E2.
58. Answer B. Autonomic dysreflexia is a relatively
uncommon but life-threatening condition in
people who have a spinal cord injury above
the level of T6
The national guidelines from the British
Association of Spinal Cord Injury Specialists state
that at all times the mean arterial pressure should
be kept above 80mmHg and a systolic pressure
above 90mmHg – in order to allow adequate
perfusion of the injured spinal cord. The ASIA
scoring system is an invaluable means of classifying and monitoring spinal injuries. The impairment scale ranges from A – complete to E –
normal, with ASIA C ‘motor incomplete’. The risk
of venous thrombosis is very high in patients with
SCI and in particular fatal PE. UK guidelines
support both physical and chemical prophylaxis
upon hospital admission to reduce this risk (Gall
et al. 2008). It is very important to recognise
autonomic dysreflexia: a potentially lifethreatening condition. The most common causes
of autonomic dysreflexia are bladder and bowel
distension. Symptoms and signs include raised
BP, bradycardia, pounding headache, flushing,
sweating or blotching above level of injury; pale,
cold, goosebumps below level of injury. It requires
immediate treatment. Paralysed patients are at
risk of developing painful spasms and contractures leading to musculoskeletal pain. These need
to be treated with analgesia, physiotherapy and
splints.
BOAST. Boast – The Management of
Traumatic Spinal Cord Injury; 2022. https://
www.boa.ac.uk/resources/knowledge-hub/boast8-pdf.html.
Gall A, Turner-Stokes L, Guideline
Development Group. Chronic spinal cord
injury: management of patients in acute hospital
settings. Clinical Medicine (London, England)
2008;8:70–74.
National Institute for Health and Care
Excellence (NICE). Recommendations: Spinal
injury: Assessment and initial management:
Guidance; 2016. https://www.nice.org.uk/guidance/
ng41/chapter/Recommendations#communicationwith-tertiary-services.
Tumour
59. Answer D. Notochord
The history and histology description are characteristic of a chordoma. The vacuolated cells on
biopsy are typically described as physaliferous.
This develops from primitive notochordal tissue,
which forms within the mesoderm in the midline
of the embryo. Surgery is undertaken when possible with wide margin resection.
60. Answer B. CT scan chest, abdomen and pelvis
The MRI scan shows likely metastatic lesions to
L2, L3 and L4, with marrow replacement showing dark on T1, with some compression of the
cauda equina on the axial image. A haemangioma shows high signal in both the T1- and
T2-weighted sequences. While radiologically
there is compression of the cauda equina, the
patient at this point has no neurological signs
or symptoms. Before any sort of treatment can
be considered, the lesion must be staged and
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Spine I Structured SBA
graded. A CT scan to look for a primary metastasis and assess for other metastases would be a
logical next step, along with blood markers
including PSA. Further treatments will depend
on the investigations and clinical picture.
61. Answer C. Decompression and stabilisation
This is a presentation of metastatic prostate
cancer with cord compression. Decision making
in thes e cases is not straightforward. Scoring
systems such as Tokuhashi are of some use, but
the specifics of these systems are likely beyond
the level of the FRCS exam. But most surgeons
would agree that in a patient presenting with
good background function and life expectancy
over 3 mon ths, progressive weakness and who
at this point is ambulatory, surgery is indicated.
Biopsy is preferable to confirm a diagnosis before
treatment but would lead to unacceptable delay
in this case, given the progressive neurology.
Level 1 evidence by Patchell et al. (2005) has
identified that surgical decompression and stabilisation lead to better outcomes than radiotherapy alone. Likewise, decompressive laminectomy
alone is rarely indicated, as the cord compression
tends to be anterior, as in this case, and posterior
decompression may result in instability. En bloc
excision is not indicated in widespread metastatic
disease.
Patchell RA et al. Direct decompressive sur-
gical resection in the treatment of spinal cord
compression caused by metastatic cancer: a randomised trial. Lancet 2005;366:643–648.
Tokuhashi Y, Matsuzaki H, Oda H, Oshima
M, Ryu J. A revised scoring system for preopera-
tive evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976) 2005;30:2186–2191.
62. Answer D. The pathological lesion tends to be
placed on the concavity of the scoliosis
The description is classically of an osteoid
osteoma, which tends to affect the posterior
elements of the spine. By definition, the radiolucent nidus is <1cm. The lesion tends to be placed
on the concavity of a scoliosis, presumably
resulting in spasm to initiate the curve.
Radiofrequency ablation is commonly used in
treatment of peripheral skeletal osteoid osteomas, but intralesional resection is the treatment
of choice in the spine, with low recurrence rates.
63. Answer C. Observation
The lesion is characteristic of a haemangioma,
which is likely a chance finding given the location of her pain relative to the lesion. This benign
lesion typically requires no treatment. On rare
occasions, when associated with unremitting
pain, vertebroplasty, curettage or resection and
reconstruction can be undertaken.
64. Answer A. Medical management
This history and investigations suggest multiple
myeloma. In general, this condition is treated
medically and rarely requires spinal surgery. At
this time medical management of his chemotherapy by a haematologist/oncologist is appropriate.
He has no clinical signs of metastatic cord compression; decompression is not indicated. As he is
ambulating freely with normal alignment, no loss
of height or posterior structure involvement on
scan the spine is likely stable; stabilisation is not
indicated. Vertebroplasty or kyphoplasty can be
indicated for pain relief and is commonly effective
in cases of myeloma with refractory pain despite
adequate treatment of myeloma and analgesia.
Radiotherapy could also be indicated.
65. Answer A. Bilobed eosinophils
Langerhans cells histiocytosis is a proliferation of
dendritic cells within the vertebral body. This
may lead to collapse and a characteristic vertebra
plana. On biopsy, bilobed ‘ coffee bean’ eosinophils in eosinophilic cytoplasm are characteristic.
On electron microscopy, tennis racquet-shaped
‘Birbeck granules’ are seen.
D is in keeping with osteosarcoma. Small
round blue cells are seen in several tumours,
including Ewing’s sarcoma. B is characteristic of
myeloma. Giant cells may be seen in LCH but are
more in keeping with a giant cell tumour.
66. Answer E. RANKL antagonist
Denosumab is a RANKL antagonist increasingly
used in the management of GCTs, bone metastases
and osteoporosis. RANKL is produced by osteoblasts in response to tumour-produced PTHrP.
RANKL binds RANKL receptors on the osteoclast,
increasing bone resorption. Osteoprotegerin is the
physiological antagonist to RANKL. Inhibition of
farnesylpyrophosphate synthase is a mechanism of
action of aminobisphosphonates.
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Paul Rushton and Niall Eames
67. Answer A. Administer oral dexamethasone
This is clearly a case of metastatic spinal cord
compression. Given the symptoms have been progressing slowly over 5 days, MRI imaging could
safely be undertaken at the DGH first thing in the
morning as there is no role for emergent, out-ofhours, surgery in this case. Dexamethasone should
be given and may improve or stabilise the neurological picture to allow suitable workup to be completed, including a CT of chest, abdomen and
pelvis. From the available information, surgery is
likely indicated and offers the patient a better outcome than radiotherapy (see Question 39).
68. Answer B. Posterior stabilisation
This patient presents with metastatic spinal disease
manifesting in instability pain based upon the history and imaging description provided. He has no
clinical cord/cauda equina compression to suggest
decompression is necessary at this point.
Vertebroplasty or radiotherapy will not address the
mechanical instability of the spine. Stabilisation is
indicated.
The Spinal Instability Neoplasic Score can be
applied in theses settings (SINS). This case scores
14 [region = junctional (3), mechanical pain].
Fisher CG et al. A novel classification system
for spinal instability in neoplastic disease: an
evidence-based approach and expert consensus
from the Spine Oncology Study Group. Spine
(Phila Pa 1976 ) 2010;35:E1221–9.
69. Answer B. Biopsy
The history and imaging are suggestive of an
isolated renal cell metastasis, but biopsy must
be undertaken to confirm the clinical picture.
Embolisation would result in tumour necrosis
and compromise the yield from a biopsy. But
embolisation would be advisable before surgery,
which would most likely be en bloc resection and
reconstruction in the setting of a truly isolated
renal cell metastasis.
256
Section 2
Chapter
12
Adult Elective Orthopaedics and Spine
Spine II Structured SBA
Prasad Karpe
SPINE II STRUCTURED SBA QUESTIONS
1. A 40-year-old patient with a background of ankylosing spondylitis with spinal deformities has
arrived at the ED after an RTA at 70 mph. He is
conscious and speaking, with a blood pressure of
90/60 mm Hg and HR of 120.
Which of the following is likely to negatively
affect the outcome of this patient?
A. Assess airway and breathing and start high-
flow oxygen
B. FAST scan
C. Pass 2 large IV bore lines and assess for sites
of bleeding
D. Trauma CT scan
E. Triple immobilisation of the cervical spine
with rigid collar
2. Which of the following statements is true
regarding pelvic incidence?
A. It changes with posture like other parameters
of pelvic morphology
B. It is pelvic tilt minus the sacral slope
C. It is the angle formed between a line drawn
from the centre of the S1 end plate to the
centre of the femoral head and a second line
drawn perpendicular to the S1 end plate,
intersecting it at the centre
D. Lower pelvic incidence necessitates more
lumbar lordosis to maintain sagittal balance
E. There is no correlation between pelvic
incidence and the Meyerding grade of
spondylolisthesis
3. A 13-year-old girl is seen in the paediatric clinic
with scoliosis. It was noticed by her mother 18
months ago that it is gradually getting worse.
Which of the following is not an indication of
MRI scan of the full spine?
A. Asymmetric abdominal reflexes on
examination
B. Axillary and inguinal freckling on
examination
C. Left-sided curve on X-rays
D. Rib prominence on forward bending
E. Right-sided short angular curve on X-rays
4. An 8-year-old boy has come to the orthopaedics
clinic with back pain and scoliosis. The boy’s
mum mentions that the pain is more prevalent
at night and has responded to anti-inflammatory
agents.
Which of the following is the only TRUE statement about this condition?
A. Fine cuts of CT and MRI scan help best in
determining treatment plan
B. It is larger than 2cm in diameter
C. It is most often present with neurological
deficit
D. Radiofrequency is the first line of treatment
in all lesions
E. The lesion is typically present on the convex
side of the scoliosis
5. A 40-year-old man has arrived in the ED with
penetrating injury to his upper abdomen. His BP
is 100, HR 110 and RR 20. He has 15/15 GCS and
normal neurology in all four limbs.
His CT shows minimal tear to his descending
aorta with no bony injuries. He undergoes laparotomy with repair of the descending aorta. His
surgery lasts for 4 hours under general anaesthesia, with his blood pressure always above
110mmHg. Post-operatively he wakes up with
weakness of the muscles in his foot, reduced
sensations in both lower limbs but intact proprioception. His power, sensations and proprioception are normal in both upper limbs. His
257
Prasad Karpe
blood pressure now is 120mmHg, HR 90, SaO
100% on 2 litres of oxygen, RR 18.
Which of the following is the MOST likely
cause of the patient’s weakness?
A. Central cord syndrome
B. Damage to feeding vessel from the left side
between T8 and L1
C. Neurogenic shock
D. Posterior cord syndrome
E. Spinal shock
6. A 60-year-old man with a background of hyper-
tension has been referred by his GP with symptoms of low back pain, neurogenic claudication
and gait disturbances. On examination, he has
brisk reflexes in all four limbs and 4/5 power in
all four limbs. Hedenies anysymptoms ofbowel or
bladder dysfunction. His lumbar spine is tender in
the region of the facets, and lumbar extension is
painful. Both pedal pulsations are well felt. His GP
has already performed an MRI ofthe lumbar spine
that shows severe canal stenosis at L3/4 and L4/5.
The NEXT most appropriate step in the management of this patient is which of the following?
A. Facet joint injections lumbar spine
B. Laminectomy L3–L5
C. Laminectomy, medial facetectomy and
instrumented fusion
D. MRI of cervical and thoracic spine
E. Transforaminal interbody fusion L3/4 and L4/5
7. Which of the following is a true statement
regarding the Smith–Robinson (anterior cervical spine) approach?
A. Dissection of the longus colli muscle risks
damage to the parasympathetic chain
B. Hyoid bone roughly lines up with C5
C. The location of the maxilla decides the ease of
access to the C2/3 disc
D. The superficial fascia, pretracheal fascia and
prevertebral fascia are encountered from
superficial to deep
E. Utilises the plane between the carotid sheath
laterally and the trachea with internal jugular
medially
8. A 68-year-old female sustains an osteoporotic
fracture. After failure of conservative treatment,
she undergoes vertebroplasty.
2
Which of the following statements is correct
regarding this procedure?
A. Chemical des truction of the nerve endings
due to chemical composition of the cement
has been proposed
B. Vertebroplasty has more advantages than
kyphoplasty
C. Vertebroplasty is indicated in patients with
ongoing pain after recent unhealed fracture,
pain confirmed at the level of fracture byexamination and MRI showing low signal on T2
D. It works by destruction of the nerve endings
due to extreme low temperature reached by
the polymerisation of the injected cement
E. It works by stabilisation of the fractured bone
by forming a chemical bond
9. An 8-year-old boy presents with fever and low
back pain. He is very tender in the L2/3 region.
Hip and knee examinations are normal. His
inflammatory markers are raised.
Which of the following is a true statement
about this condition?
A. Disc space narrowing is the earliest radio-
graphic sign
B. Batson plexus is the most common pathway
of mode of spread to spine
C. Most common organism is Staphylococcus
aureus
D. CT imaging is the investigation of choice
E. Vertebral end plates get infected first
10. Which of the following is not an imaging find-
ing for spinal infection in adults?
A.
Loss of disc height and abnormal disc signal
B. Loss of end plate definition on both sides of
the disc
C. Paraspinal soft tissue or loculated fluid
collection
D. Posterior elements are most commonly affected
E. Vertebral collapse
11. The root value of the ankle reflex is which of
the following?
A. L3/L4
B. L4/L5
C. L5/S1
D. S1/S2
E. S2/S3
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Spine II Structured SBA
12. An 11-year-old girl comes to the spinal clinic
with recent onset of noticing deformity. She has
no neurology in her legs and no generalised
syndromic features. AP radiograph of her spine
is as depicted in Figure 12.1.
Which of the following is true about paediatric
spinal trauma?
A. Injury to the spinal cord can only happen
with visible changes on X-rays and CT scan
B. CT scan is the investigation to diagnose
injury to the cord and ligament injuries
C. Upper cervical trauma is more common in
children younger than 8 years of age
D. The child should be immobilised on a stand-
ard spinal board
E. There can be a normal anterior translation
between C5 and C6
14. A 30-year-old male ankylosing spondylitis
patient with kyphosis needs a sagittal correction
spinal procedure.
Which of the following statements correctly
describes pedicle subtraction osteotomy?
A. Correction happens at the level of the verte-
bral body and not the disc
B. It opens up the anterior column, closes the
middle column somewhat and closes the posterior column
C. It is classically performed at T11/T12 vertebrae
D. It provides more correction than Smith-Petersen
osteotomy and vertebral column resection
E. PSO is associated with fewer complications
Figure 12.1 AP radiograph spine
Which of the following is an ideal indication of
a brace?
A. Curves greater than 40°
B. Overweight adolescent patients with curve
progression
C. Patients unable to cope emotionally with
treatment
D. Thoracic lordosis
E. Skeletally immature patients
13. A 4-year-old boy is brought unconscious to the
ED with a history of a motor vehicle accident.
15. All of the following are true about radiology in
ankylosing spondylitis EXCEPT which answer?
A. 50% of ankylosing spondylitis patients with
fractures can have normal-looking X-rays
B. The earliest sign on pelvic X-rays is erosion
on the iliac side of sacroiliac joint
C. Marginal syndesmophytes are present in the
vertebrae
D. MRI is the modality for early detection of
ankylosing spondylitis
E. Sacroiliac joint invol vement is often
asymmetric
16. A 40-year-old man visits a clinic, complaining of
chronic back pain. There are no red flags on
history or abnormalities on examination.
Which of the following is the most appropriate
method of treatment?
A. Acupuncture
B. Caudal epidural injection
C. Combined physical and psychological
programmes
259
Prasad Karpe
D. Lumbar corset or belt
E. Opioid analgesics
17. Which of the following statements about spine
anatomy is true?
A. The cell bodies of the sympathetic nervous
system are found in the lateral horn grey
matter of spinal cord segments T7–T9
B. The preganglionic sympathetic preganglionic
cell bodies lie in sacral segments S2, S3, S4
C. The C8 nerve exits the foramen superior to
the pedicle of C7
D. The inferior limit of the spinal cord in adults
is L1 or L2
E. The inferior limit of the dural sac and sub-
arachnoid space is the L2 vertebra
18. A 30-year-old man has been brought to the ED
after a motor vehicle accident. He appears
drowsy and a trauma CT shows a small contusion in the brain with 50% subluxation of the C6/
7 vertebrae. He has triple immobilisation in
place. He is also seen by neurosurgeons who
say he is able to undergo any cervical procedures.
The most appropriate next step in management
of this patient is which of the following?
A. Anterior cervical fusion
B. Cervical orthosis for 6 weeks
C. Immediate closed reduction of the
subluxation
D. MRI scan
E. Posterior cervical fusion
21. Ankylosing spondylitis (AS) and DISH (Diffuse
Idiopathic Skeletal Hyperostosis) can mimic each
other.
Which of the following is a correct statement
when differentiating the two?
A. AS have normal discs while with DISH the
discs could be ossified
B. The facet joints are normal in AS whilst fused
in DISH
C. Unilateral sacroiliac joints are involved in
DISH whilst bilateral in AS
D. There is ossification of ligaments and
entheses in DISH while erosive enthesopathy
in AS
E. Marginal syndesmophytes in DISH and
flowing periosteal reaction/non-marginal in
AS
22. A 13-year-old boy with a background of cerebral
palsy presents with the deformity as depicted in
sitting spinal radiographs (Figure 12.2).
19. A patient with T4 spinal cord injury and paraplegia is not likely to have which of the
following complications?
A. Autonomic dysreflexia
B. Major depressive episode
C. Orthostatic hypertension
D. Urosepsis
E. Venous thromboembolism
20. Which of the following pelvic parameters does
not change on posture?
A. Lumbar lordosis
B. Pelvic incidence
C. Pelvic tilt
D. Sacral slope
E. Sagittal vertical axis
260
Figure 12.2 Sitting radiographs spine
Spine II Structured SBA
Which of the following statements is true
regarding this type of scolios is?
A. It usually presents later than most cases of
idiopathic scoliosis
B. It responds well to orthotic treatment
C. Surgical treatment is rarely needed
D. It tends to exhibit longer curves as compared
with idiopathic scoliosis
E. It is less like ly to progress in severity
23. A 15-year-old boy presents with Duchenne mus-
cular dystrophy. He has a scoliotic curve measuring 35° with apex at T11 and pelvic obliquity.
Which of the following is the most appropriate
next step in management?
A. Bracing
B. Combined anterior and posterior fusion
C. Long segment fusion
D. Observation
E. Short segment posterior fusion
24. Which of the following is not a criterion for
recommending surgery for thoracolumbar
burst fractures?
A. CT evidence of canal compromise with no
neurology
B. Disruption of posterior column
C. Greater than 50% loss of vertebral body height
D. Inability to immobilise patient in brace due
to associated injuries
E. Kyphosis greater than 25–30° at the level of
fracture
Severity (TLICS) score for thoracolumbar
fractures?
A. Canal compromise on axial CT scan
B. Injury morphology
C. MRI signal change in region of interspinous
ligaments
D. Neurology
E. Widening of interspinous distance
27. A 36-year-old man is involved in a motor vehicle
accident. He is a seat belt-restrained car passenger. He sustains a flexion distraction type of
injury of the thoracolumbar spine.
Which of the following is true about this injury?
A. It will always need surgical stabilisation
B. Injurypatternisalwaysthroughposteriorliga-
mentous complex, facet capsules and intervertebral discs
C. It will involve the middle and posterior
column of the spine
D. There is a low incidence of intra-abdominal
injuries
E. Progressive kyphosis is a known complica-
tion in unre cognised injuries
28. Which of the following is not a cause of
myelopathy?
A. Bilateral cervical facet dislocation
B. Prolapsed cervical disc
C. Multiple sclerosis
D. Myasthenia gravis
E. Vitamin B
deficiency
12
25. A41-year-oldwomaninastaticcarishitfromthe
rear by HGV. She is brought in with stable vitals and
trauma CT shows T8 fracture, multiple rib fractures
and sternal fractures. She has a chest tube inserted
for left haemothorax and has no neurological deficit. Plan for surgical stabilisation is made.
Which of the following is a factor for considering conservative treatment?
A. Canal compromise more than 50%
B. Disc in fracture
C. DISH/ankylosis spondylitis spine
D. Little or no comminution
E. Neurological compromise
26. Which of the following is not a component of
Thoracolumbar Injury Classification and
29. A 70-year-old man with a background of poorly
controlled diabetes and prostate cancer with skeletal metastases presents with gait disturbances.
There are no abnormalities in upper limb examination, but he has brisk lower limb reflexes and
upgoing plantar reflex.
Which of thefollowing is most likely to explain his
findings and will need to be investigated further?
A. Brain metastases
B. Cervical spondylotic myelopathy
C. Lumbar spine metastases
D. Peripheral neuropathy
E. Thoracic spine metastases
30. Which of the following levels is most likely to
be injured following trauma in adults?
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Prasad Karpe
A. Lower cervical spine
B. Lumbosacral spine
C. Thoracic spine
D. Thoracolumbar spine
E. Upper cervical spine
31. Return of the bulbocavernous reflex after
spinal trauma could mean which of the
following?
A. Complete spinal cord lesion
B. Incomplete spinal cord lesion
C. Neurogenic shock
D. Reversal of spinal shock
E. Sacral nerve root injury
32. A 40-year-old man is brought to the ED with a
history of a heavy object falling on his head while
performing construction work. He was wearing a
helmet and had no signs or symptoms of head
injury. He complains of neck pain and is in a
collar. He has no neurology. CT scan confirms
anterior and posterior arch fracture. Open
mouth view X-ray shows a combined lateral displacement of 5mm.
Which of the follo wing is true regarding this
injury?
A. There is a high risk of associated spinal injury
at another level
B. It is associated with a high risk of neuro-
logical injury
C. It is an unstable injury
D. Patient needs surgery in the form of C1/2 or
occipitocervical fusion
E. Transverse and alar ligaments are ruptured in
this case
33. Which of the following is true regarding a
hangman’s fracture?
A. May be due to unilateral fracture of pars
interarticularis
B. Is traumatic posterior spondylolisthesis of C2
C. Always unstable injury
D. High incidence of neurological injury
E. Caused by hyperextension with secondary
flexion
34. A 30-year-old rugby player gets involved in a
tackle. He complains of unilateral pain along
C5 and C6 dermatomes along with transient
weakness of deltoid and biceps, with normal
cervical range of motion.
Which of the following fits this pattern of
injury?
A. Brachial plexus axonotmesis
B. Cervical disc herniation
C. Cervical fracture
D. Scapula fracture
E. Stinger
35. Which of the following mechanisms is the least
likely injury pattern responsible for stinger or
burner?
A. Axial compression of the cervical spine
B. Direct blow to a point just above the clavicle
C. Hyperextension, compression and rotation
towards the involved arm
D. Lateral neck flexion with shoulder depression
E. Trauma to Erb’s point
36. Regarding intervertebral disc, which of the
following statements is true?
A. Annulus fibrosus is the outer structure that
contains predominantly type I collagen that is
vertically oriented
B. Dorsal root ganglion innervates the annulus
fibrosus through the sinuvertebral nerve
C. Nucleus pulposus contains a high collagen to
proteoglycan ratio
D. Nucleus pulposus contains predominantly
type I collagen
E. Nutrition occurs through diffusion via annu-
lus that is porous
37. Which of the follo wing is an age-related change
in the intervertebral disc?
A. Increase in disc height
B. Increase in proteoglycan
C. Increase in water content
D. Reduction in collagen
E. Reduction in nutritional transport across the
end plates
38. A 50-year-old diabetic patient undergoes posterior spinal fusion for a spinal pathology. She has
bone graft taken from the right anterior iliac
crest. Post-operatively, she is put in a TLSO and
mobilised. She complains of right anterior thigh
pain and paraesthesia immediately after surgery.
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Spine II Structured SBA
CT scan confirms no screw malposition and
pelvis X-rays are normal.
Which of the following is the least likely differential diagnosis?
A. Diabetes
B. Epidural haematoma at L4 level
C. Graft site morbidity
D. Position during surgery
E. TLSO
39. A 70-year-old woman complains of upper cer-
vical neck pain after being involved in a RTA
at 30mph. She has no neurolo gical injury on
examination. After ATLS assessment, it is evident that her neck sustained her only injury.
CT scan shows a fracture of the odontoid at the
waist.
Which of the following is true regarding the
injury pattern in this patient?
A. Anterior odontoid screw fixation is treatment
of choice fo r pseudoarthrosis
B. There is a good chance of union considering
the fracture pattern
C. There is a high risk of non-union as she is a
female
D. There is a high risk of non-union du e to her
age
E. There is a high risk of non-union if there is
delay in starting treatment
40. A 14-year-old boy is brought to a spinal clinic by
his mother after she noticed abnormal curvature
in his back. He has no history of fever, weight
loss or any significant family history. He denies
any trauma. He has no back pain. He has no
neurological deficit on examination. He has no
scoliosis but does have a significant lower thoracic kyphosis that does not correct with extension of spine. Lateral X-ray of his spine is
depicted in Figure 12.3.
The most likely diagnosis is which of the
following?
A. Congenital kyphosis
B. Normal thoracic kyphosis
C. Infection
D. Scheuermann’s kyphosis
E. Traumatic fractures of the thoracic spine
Figure 12.3
Lateral radiograph
of spine
41. A 40-year-old soldier is brought in with gunshot
wound to his back. CT and MRI scan reveal the
bullet lodged in the right half of the spinal cord at the
level of T10 in the region of the spinothalamic tract.
Which of the following examination findings is
he likely to have?
A. Loss of fine touch, pressure and vibration on
the left side, T10 downwards
B. Loss of pain, temperature and crude touch on
the left side, T10 downwards
C. Loss of pain, temperature and crude touch on
the left side, T12 downwards
D. Loss of pain, temperature and crude touch on
the right side, T10 downwards
E. Loss of pain, temperature and crude touch on
the right side, T12 downwards
42. A 30-year-old fit and well man is brought in after
being involved in a fight. He has a stab wound in
his back. He complains of loss of fine touch in his
left upper limb.
Which of the following is he likely to have
damaged?
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